Health History

Does the student have any physical or mental diagnosis that may restrict or impair their ability to

safely participate in True Blue Equine activities? This includes, but is not limited to epileptic

seizures, heart conditions, or pregnancy. YES NO

If yes, please explain:

Does the rider have a history of allergies? YES NO

Has the rider been hospitalized for an allergic reaction? YES NO

permission to engage in all program activities as noted. I understand that it is our responsibility

to provide updates (including changes in health conditions, medical coverage, or activity

restrictions) throughout the program year and prior to any events/activities in which the

member intends to participate;

If an injury or other medical condition occurs or arises, I grant permission for medical

treatment to be obtained for the student and authorize the physician and/or the other medical

staff to employ such diagnostic procedures and medical treatment as deemed necessary;

I authorize the release of any medical records necessary for treatment, referral, billing, or

insurance purposes; and

I understand that I am financially responsible for charges and hereby guarantee full payment to

Parent/Guardian:

Address:

Phone:

Email:

ICE Contact:

Relationship:

Phone:

Physician Name:

Physician Phone:

Insurance Provider: